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200512GOG r INSTRUCTIONS FOR COMPLETING TENANT INCOME CERTIFICATION 17te Tenant Income Cerd*adon form is to be completed by the owner or an authorized representative. j Pan I — Development Data Check the appropriate box for Initial Certification (move -in), Recertification (annual recertification) or Other. If Other, designate the purpose of the recertification (Le., a unit transfer, a change in household composition or other state - required recertification). Move -in Date Enter the date the tenant has or wilt take occupancy of the unit. E�tive Date Enter the effective date of the certification. For move -in, this should be the move -in date. For annual recertification, this effective date should be no later than one year from the effective date of the previous (re)certification. Property Name Enter the name of the development. County Enter the county (or equivalent) in which the building is located. BIN # Enter the Building Identification Number (BIN) assigned to the building (from IRS Form 8609). Address Fatter the address of the building. Unit Number Enter the unit number. # Bedrooms Pater the munber of bedrooms in the unit. Part II — Household Composition List all occupants of the unit. State each household member's relationship to the head of household by using one of the following coded definitions: H - Head of Household S - Spouse A - Adult co- tenant O - Other family member C - Child F - Foster child(renYadult(s) L - Live -in caretaker N - None of the above Enter the date of birth, student status and social security number or alien registration cumber for each occupant. If there are more than 7 occupants, use an additional sheet of paper to list the remaining household members and attach it to the certification. Part M -- Annual Income See HLD Handbook 4350.3 for complete Instructions on verifying and calculating income, Including acceptable forms of verification. From the third -party verification forms obtained from each income source, enter the gross amount anticipated to be received for the twelve months from the effective date of the (re)certification. Complete a separate line for each income- earning member. List the respective household member number from fart II. Column (A) Enter the annual amount of wages, salaries, tips, commissions, bonuses and other income from employment; distributed profits and/or net income from a business. Column (B) Enter the annual amount of Social Security, Supplemental Security Income, pensions, military retirement, etc. Column (C) Enter the annual amount of income received from public assistance (i.e., TANL F, general assistance, disability, etc.).